Provider Demographics
NPI:1912588062
Name:MONTGOMERY, DEBRA R
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:R
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N JOE WILSON RD APT 1326
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2341
Mailing Address - Country:US
Mailing Address - Phone:708-465-5271
Mailing Address - Fax:
Practice Address - Street 1:24493 S INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2069
Practice Address - Country:US
Practice Address - Phone:708-465-5271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL854399202Medicaid